Page 3 - Full_Application_for_print
P. 3
APPLICATION FOR SERVICES
Head of Household Name
1. Complete the application and return it to Community Services of Northeast Texas, Inc.:
____ for all services: use the Outreach Center in your county (see list on back page)
____ for Utility Assistance ONLY, Mail to:
CSNT, Inc.
Utility Assistance
P.O. 427
Linden, Texas 75563
2. Include all the required documentation indicated on the enclosed list.
3. We will most likely conduct a phone interview with you. Do you have any physical or
mental conditions that require special accommodations?
If so, please explain so we can better serve your family’s needs.
__________________________________________________________________
__________________________________________________________________
Your timely response will expedite processing for assistance.
FOR AGENCY USE ONLY
Date Requested Sent Date Date Received Appt. Interview Location
Date/Time
□ Phone
By: _________ By:________ □ Center_____________
□ Home Visit
Version 9.17
Community Services of Northeast Texas, Inc. • Box 427 • Linden, TX 75563
Page 3
